(718) 732-0222

(718) 732-0222

ORTHOPEDICS

PATIENT LAST NAME

PATIENT FULL FIRST NAME

CLINICAL INDICATIONS/SIGNS/SYMPTOMS (NOT RULE/OUT):

TODAY'S DATE ICD-10:

DATE OF BIRTH

PHYSICIAN SIGNATURE (REQUIRED) PHYSICIAN NAME (PRINTED OR STAMPED)

PHYSICIAN ADDRESS

patients:

call to make an appointment

take a cell phone photo of this form and text or email it to rx@

MRI (magnetic resonance imaging)

CT (computed tomography)

X-RAY

16 MRI Chest: No IV Contrast 71550

Pectoralis Tear

SC Joint Pain

Sternal Trauma

Brachial Plexus

29 MRI Upper Extremity Joint: No IV Contrast 73221

R L Shoulder Indications:

Fracture

R L Elbow

Joint Pain

Labral Tear

R L Wrist

Arthritis

Ligament Tear

Bursitis

Tendon Tear

30 MRI Upper Extremity Joint: Pre + Post IV Contrast 73223

R L Shoulder Indications:

Infection

R L Elbow

Abscess

Mass

R L Wrist

Tumor

Osteomyelitis

31 MR Arthrogram Upper Extremity Joint:

R L Shoulder Arthrogram 73222/23350

R L Elbow Arthrogram 73222/24220

84 CT Cervical Spine: No IV Contrast 72125

85 CT Thoracic Spine: No IV Contrast 72128

86 CT Lumbar Spine: No IV Contrast 72131

87 CT R L Upper Extremity: No IV Contrast 73200

Fracture Pain

Clavicle Shoulder Scapula

Humerus Elbow Forearm

Wrist Hand Fingers

88 CT R L Upper Extremity: Post IV Contrast Only 73201

Tumor Infection

Clavicle Shoulder Scapula

Humerus Elbow Forearm

Wrist Hand Fingers

120 X-Ray Head

Skull Nasal Bones Facial Bones

122 X-Ray Chest

Chest Right Ribs Left Ribs

Sinus Orbits For Foreign Body Orbits-Complete

Bilateral Ribs Sternum Sternoclavicular Joints

124 X-Ray Spine

Cervical AP, LAT, APOM

Add Obliques Add Lateral Flexion/Extension Add AP Right & Left Lateral Bending

R L Wrist Arthrogram 73222/25246

32 MRI Upper Extremity Non-Joint: No IV Contrast 73218

R L Humerus

Indications:

R L Forearm

Fracture

89 CT Arthrogram R L Upper Extremity

Shoulder Elbow

Wrist

Other: ________

73201/23350 73201/24220 73201/25246

Thoracic AP, LAT Add Obliques

Lumbar AP, LAT Obtain Lumbar Films Upright

R L Hand

Muscle Tear

90 CT R L Lower Extremity: No IV Contrast 73700

R L Finger Specify#:

Tendon Tear

Hip

Tib/Fib

33 MRI Upper Extremity Non-Joint: Pre + Post IV Contrast 73220 Fracture Femur

Ankle

R L Humerus

Indications: Pain

Knee

Foot

R L Forearm

Tumor

Knee W/ Patella Tracking Toes

R L Hand

Infection

Indicate Degrees:________

R L Finger Specify#:

Osteomyelitis

34 MRI Lower Extremity Joint: No IV Contrast 73721

R L Hip Indications:

Meniscal Tear

R L Knee Pain

Ligament Tear

R L Ankle Fracture

Cartilage Tear

91 CT R L Lower Extremity: Post IV Contrast Only 73701

Tumor Infection

Hip Femur Knee

Tib/Fib Ankle

Foot Toes

Internal Derangement Instability

92 CT Arthrogram R L Lower Extremity

Labral Tear

35 MRI Lower Extremity Joint: Pre + Post IV Contrast 73723

R L Hip Indications:

Osteomyelitis

Hip

Knee

Ankle Other: ________

73701/27093 73701/27370 73701/27648

R L Knee

Tumor

Cellulitis

R L Ankle Infection

36 MR Arthrogram Lower Extremity Joint

78 CT Pelvis: No Oral, No IV Contrast 72192

Bony Pelvis

Sacrum/Coccyx

R L Hip Arthrogram 73722/27093

SI Joints

R L Knee Arthrogram 73722/27369

R L Ankle Arthrogram 73722/27648

37 MRI Lower Extremity Non-Joint: No IV Contrast 73718

R L Femur/Thigh

Indications:

83 CTA Runoff: No Oral, Post IV Contrast Only 75635

Claudication

Occlusion

Stenosis

R L Tib/Fib / Calf R L Foot

Fracture Muscle Tear

93 Other

Add Obliques Add Lateral Flexion/Extension Add AP Bending To R & L

Sacrum/Coccyx

Scoliosis Series (Always Upright)

125 X-Ray Extremities

R L BILATERAL

ACSSHFihc/lnaaCaognvpuJedioculrdilnleSaetprsecifyHEFWB#oloub:rrnmioesetaweArrmugse

Pelvis

Weight-Bearing

Hip

Weight-Bearing

Femur

Knee

Weight-Bearing

Tibia/Fibula

Ankle

Calcaneus

Foot

Weight-Bearing

Toe Specify #:

NUCLEAR MEDICINE R L Toe Specify#:

Tendon Tear

38 MRI Lower Extremity Non-Joint: Pre + Post IV Contrast 73720

126 Skeletal Xray Survey

R L Femur/Thigh R L Tib/Fib / Calf

Indications: Tumor

220 Bone Scan?Whole Body 78306

127 Other

R L Foot R L Toe Specify#:

Soft Tissue Mass Osteomyelitis

221 Bone Scan 3 Phase 78315 Region

DEXA

27 MRI Pelvis: No IV Contrast 72195

Pelvic Pain

SI Joint Pain

222 Bone Scan Spect 78320 Region

Sacral/Coccyx Pain

39 MRA ABD/PEL and Lower Extremity Runoff: Post IV Contrast

223 Other

160 Dexa Hips, Lumbar, Wrist 77080 161 Dexa Hips, Lumbar 77080 162 Dexa with LVA 77085

74185, 72198, 73725, 73725 Claudication

Indications:

40 MRI Cervical Spine: No IV Contrast 72141

Neck Pain

Disc Herniation

ULTRASOUND

INTERVENTIONAL

Numbness

Trauma

Radiculopathy

41 MRI Cervical Spine: Pre + Post IV Contrast 72156

Syrinx

Tumor/Mass

108 Extremity Doppler Ultrasound

Venous for DVT Upper Lower Bilateral 93970 Right 93971 Left 93971

176 MSK Fluoro-Guided RT LT Shoulder Aspiration Injection 77002/20610

Discitis

Osteomyelitis

Multiple Sclerosis

42 MRI Thoracic Spine: No IV Contrast 72146

Pain

Trauma

Disc Herniation

Compression Fracture

Radiculopathy

43 MRI Thoracic Spine: Pre + Post IV Contrast 72157

Syrinx

Tumor/Mass

Pain Edema Difficulty walking Shortness of breath

Arterial Upper Bilateral 93930 Right 93931 Left 93931

Elbow Wrist Hip Knee Ankle Foot

Aspiration Aspiration Aspiration Aspiration Aspiration Aspiration

Injection 77002/20605 Injection 77002/20605 Injection 77002/20610 Injection 77002/20610 Injection 77002/20605 Injection 77002/20605

Discitis

Osteomyelitis

Multiple Sclerosis

44 MRI Lumbar Spine: No IV Contrast 72148

Lower Back Pain

Disc Herniation

Numbness

Radiculopathy

Trauma

Leg Pain

45 MRI Lumbar Spine: Pre + Post IV Contrast 72158

Discitis

Tumor/Mass

Post-Op

Arterial Lower Bilateral 93925 Right 93926 Atherosclerosis Claudication Pelvic Pain

109 US Extremity 76881 R

Body Part:

Left 93926

L

177 MSK Shoulder Elbow Wrist Hip Knee

Ultrasound-Guided RT LT Aspiration Injection 20611 Aspiration Injection 20606 Aspiration Injection 20611 Ganglion 20612 Aspiration Injection 20611 Aspiration Injection 20611

46 Other

119 Other

Ankle Aspiration Injection 20606

178 Other

RAD

(718) 732-0222

TOWN

ADDRESS

TRANSIT

FAX NUMBER

MANHATTAN HARLEM

324W 125th St, 10027

BRONX PARKCHESTER 1888 Westchester Ave, 10472

BROOKLYN COBBLE HILL 205 Smith Street, 11201

CROWN HTS 1128 Eastern Pkwy, 11213

QUEENS BAYSIDE

213-02 Northern Blvd, 11361

ELMHURST LAURELTON OZONE PARK

88-12 Queens Blvd, 11373 231-35 Merrick Blvd, 11413 102-34 Atlantic Ave, 11416

ACBD

(718) 696-0767

M3, M10, M100, M101, M60, BX15

6 Q44, BX4, BX4A, BX36, BX39 (718) 696-0193

FG

B57

(718) 684-7425

2 3 4 B14, B17, B46 (718) 684-7438

Q12, Q13, Q27, Q31, QM3, n20, n20G (718) 684-7423

RM Q5 Q24

Q59, Q60

(718) 684-7427 (718) 684-7421 (718) 684-7429

95 95

BRONX 895

Yankee Stadium

1888 WESTCHESTER AVE PARKCHESTER

695

324W 125TH STREET HARLEM

278 SOUNDVIEW

295 678

THROGS NECK

678 278

MANHATTAN DR Dri rand Central Pkwy

ve F

WHITESTONE COLLEGE POINT

Cross Isla

907 NORTHERN BLVD GREAT NECK

nd Pkwy

278

ASTORIA

La Guardia Airport

Grand Central Pkwy

678

FLUSHING

213-02 NORTHERN BLVD

MURRAY HILL

BAYSIDE

LITTLE NECK

JACKSON

HEIGHTS

678

WOODSIDE

295 495

25 495

SUNNYSIDE

278 495

GREENPOINT

88-12 QUEENS BLVD

25 ELMHURST

295 495

FRESH MEADOWS

495

REGO PARK

FOREST MIDDLE VILLAGE HILLS

QUEENS

25

C

ross Island Pkwy

G

25

1390 HEMPSTEAD TPKE ELMONT

WILLIAMSBURG

RIDGEWOOD

278

205 SMITH STREET COBBLE HILL

BUSHWICK

BEDFORD-STUYVESANT

RED HOOK

1128 EASTERN PKWY CROWN HEIGHTS

678 25

102-34 ATLANTIC AVE OZONE PARK

QUEENS VILLAGE

231-35 MERRICK BLVD

ST ALBANS

LAURELTON

278

PARK SLOPE

27

BROOKLYN

BROWNSVILLE EAST NEW YORK

Belt Pkwy

HOWARD BEACH

678

Belt Pkwy SPRINGFIELD

GARDENS ROSEDALE

John F. Kennedy International Airport

VALLEY STREAM

EAST FLATBUSH CANARSIE

BOROUGH PARK

FLATLANDS

MIDWOOD

625 ROCKAWAY TPKE LAWRENCE

HEWLETT WOODMERE

INWOOD

WOODSBURGH

CEDARHURST

6/19

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